Monday, April 27, 2009

When death's not always an evil

April 25, 2009

By Andy Ho

AUSTRALIAN euthanasia outfit Exit International is running a right-to-die workshop here to pass on to locals some swift and painless technologies of death.

[Note: Exit International has clarified that they are not going to give tips on committing suicide in view of local laws. Dr Nitschke said that his talk would focus on the need to change existing legislation.]

This promises to reignite the debate that Health Minister Khaw Boon Wan sparked last year when he suggested that we debate euthanasia. Then, as now, rising costs of end-of-life medical care would be a pressing issue in the debate.

[Note: Minister of Health clarified that MOH is not promoting euthanasia. Rather he wanted to open dialogue on end-of-life issues so that people could discuss more openly about the various options - inlcuding sending Ah Kong to JB. Sorry. Could not resist. :-)]

But economics is unhelpful with moral issues for it calibrates goodness merely in terms of value that can be traded. Instead of asking 'How much do you care about this dying person?' it asks 'How much time and money would you trade to keep him alive?'

The question of euthanasia's ethical status - its goodness or badness - is surreptitiously transformed into a monetary issue. We don't think about loved ones that way, so the debate will likely continue to pit two immovable moral principles against each other: namely, sanctity-of-life versus right-to-die. The positions being totally incommensurable, there is no resolution in sight.

Actually, neither principle is iron clad. For example, narcotics are used to relieve pain in extremis though this can suppress breathing, which hastens death. Sanctity-of-life proponents accept the use of narcotics, judging the end of pain relief to be more important than the means used to accomplish the end, which in this case can also hasten death.

Yet how does distinguishing a possible effect (hastening death with pain killers) from intending it (killing intentionally) explain why this exception is permissible? Labelling two outcomes differently and then asserting that one trumps the other is no explanation. To dress it up, the doctrine of double effect has been proposed: It is just that narcotics relieve pain (good effect) though they can kill too (bad effect). More labelling?

The right to a good death is not an unproblematic notion either. Intuition tells us it is only when we know what is good that we know what is right. We can only have a right when we can pin down what the good thing is that the right serves to protect.

But no one has proven that death for the terminally ill is an unequivocally good thing since no one has proven that no hereafter exists. Near-death experiences suggest the opposite, if anything.

If there is nothing but an eternity of sublime bliss - or just nothingness - well and good. But should it be an interminable payback time of hellfire - or reincarnating as an ass, say - euthanasia could amount to trading a bad situation for a worse one.

So neither principle - sanctity-of-life or right-to-die - is faultless. Yet, in tandem, they have gridlocked the debate. Experts suggest that the gridlock might have arisen in the following way.

First, certain paradigmatic cases were scrutinised and principles were derived from them. One paradigmatic case would be a terminally ill patient without pain relief despite the finest palliative care who wishes to die but is kept alive anyway. The opposite one would be a wealthy disabled person who wants to live but relatives after his money set him up so he is euthanised.

From such cases are derived the principles that a patient's will is paramount or that life is precious regardless. So far so good. But then things go awry when the latter principle is applied to the former type of cases, or vice versa.

Alternatively, a principle is applied to the correct type of case - precious is the life of a pregnant mother with exsanguinating vaginal bleeding - but it is in conflict with another case - precious also is the life of the baby but it must be sacrificed when completely removing the womb is the only way to stop the woman bleeding to death. Proponents then furnish the ad hoc double effect doctrine.

One way that has been suggested to break this gridlock is to not begin by deciding which principle controls the analysis. Instead, just examine each case on its own merits to see if something is good or evil.

But can we trust our intuitions? Take killing babies just for fun. Without pulling out the sanctity-of-life banner, we can intuit that this is wrong.

Or, consider the Austrian monster dad Josef Fritz who locked his daughter Elisabeth in the basement and sexually abused her for 24 years to father seven children. We grasp immediately without resorting to the notion of Elisabeth's right-to-life that this was definitely evil.

Now take a terminally ill patient in severe pain. Narcotics can relieve the pain but they also cause him to drift in and out of consciousness. Moreover, they cause intractable constipation which is seriously distressful as well. So sometimes we go easy on the narcotics but pain returns.

It is the final chapter in the story of a whole life of someone who isn't fully the person he was before but our love for him is not thereby diminished. In this context of loving someone who can get no unsullied relief from unremitting pain and distress, a swift and painless death is intuitively an unmitigated good, not evil.

Still most of us also intuit death as something intrinsically evil. But is it? In July 2003, Iranian conjoint twins Ladan and Laleh Bijani asked their neurosurgeon here to proceed with separation surgery even if it led to death, which it did.

If death is not always an evil, the crux of the matter is not whether right-to-die trumps sanctity-of-life, or vice versa. The root question is whether death is an evil in your own particular case. We must each deal with this unflinchingly and answer it for ourselves unequivocally. Then only should we acquire the technologies of death for an Exit.

[I am tempted to snidely remark that Dr Ho argued a whole column to conclude: it depends. But I am inclined to his view - that there is no universal right or wrong, or that right or wrong is completely dependent on the situation and the person facing the situation. Even similar circumstances with similar philosophy may lead to differing personal choice. An atheist with terminal cancer and in horrendous pain, kept alive and lucid only with enough painkillers to knock out a horse - he may decide that he has run the good race, and would like to go gentle into the good night. Another atheist in the same situation, knowing that there is no life after death (or believing so), may feel that pain is a price for life and no price is to high.

But Dr Ho does not go one further. To argue whether death is evil or not is to attribute a moral judgement on a natural fact. Everyone dies. Everything that lives, dies. Does this mean that whatever one's achievement, ultimately an evil will be done to one at the end of life? That is nonsense.

Death is neither evil nor good. Murder is evil. Suicide due to depression is bad mainly because one is not in one's right mind when one kills oneself. Suicide mission for nation and country is heroic. But then "suicide" in this case is instrumental to military objectives. So the act of killing oneself or putting one in danger such that death is imminent and inevitable is good or bad depending on the situation and the state of mind of the person. (So if a depressed soldier volunteers for a suicide mission is it good or bad? Do we talk him out of it and send someone else - who doesn't really want to die - on the suicide mission? And counsel the suicidal one until he gets better? Only to see him kill himself uselessly later on?)

What is clear is that death is an inevitable fact of life. It is neither evil nor good. It is how one chooses to meet death that may be subject to moral judgement or assessment. If one chooses death early to escape from one's responsibility or because of one's inability to deal with or cope with life, then we may say that that person has opted out of life, or even rejected the gift of life for the most trivial of reasons.

If one chooses death because one has achieved all that one could hope for and used the talents given to one, and one is at peace, then that is a good death.

For those in pain or with terminal illness, they should make a medically-informed decision based on facts and probabilities, and best and worst case scenarios.]

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